Updosing go resolve tolerance withdrawal

Hi everyone

I’ve been on the same dose of zolpidem/ambien for a year with no problem (4.8mg) and out of nowhere am suddenly experiencing the most extreme withdrawal effects, without changing the dose. My central nervous system is in a terrible state, I’m not sleeping, I’m suffering panic all day...

My question is, does updosing ever resolve this? You calm the nervous system by updosing, and then it will allow you to taper? Or will the withdrawal simply kick in again once you reach the previous dose? I really don’t think I can taper from the state I’m in, so I’m looking into a solution...

Katie

Ktkat999, I'm really sorry to hear how much you're suffering!

The usage lifespan of these drugs varies by individual, and probably due to a wide range of factors. It does sound from what you're sharing that you are in tolerance withdrawal. From what I understand, updosing will only delay your need to taper off the medicine briefly; you can do it, and it might be recommended by your doctor as a short-term fix.

I wonder if a crossover to a longer acting benzo would be more help, both for tapering and your tolerance withdrawal. Do you have a supportive doctor? Have you tried diazepam?

At 4.8mg zolpidem your Ashton equivalent diazepam dose would be 2.4mg. A step-wise, month-long crossover would be recommended by Ashton.

http://benzo.alwaysdata.net/tools/conversion.php

Thanks so much for your reply. So if I updose then the tolerance will just catch with me again? I was hoping if I soothed the nervous system enough with an updose whether tapering from there might be easier?

I have been thinking about a crossover. But if I’m in tolerance withdrawal with zolpidem, wouldn’t I just move into tolerance withdrawal with valium?

Also, the crossover scares me and I have no idea how to do it... Ashton recommends half diazepam/half zolpidem just for one week and then straight into the full diazepam, but surely that’s too quick? Do you by any chance have any information on how to do crossovers safely?

Thanks so much for your help

Zolpidem has a 2 hour half-life; that's pretty crazy fast. Alprazolam (Xanax), by comparison has a 6-12 hours half-life.

I honestly could not find Ashton's crossover schedule for zolpidem. The two-step crossover you describe doesn't sound unreasonable to me, given zolpidem's short half-life and that you're in tolerance to it currently. It seems to me to take about a week for a sufficient amount of diazepam's primary metabolite to build up for the full therapeutic effect to take place. Doing this crossover in two steps could work; you could also make it three or four steps if you want. We could discuss how to do this if you were interested, keeping in mind that I am NOT well-versed about zolpidem, just crossovers to diazepam.

I don't think you would continue to be in tolerance withdrawal with diazepam; I can't say for sure. It's going to have a half life that could be 100x as long as zolpidem for you. This makes tapering much much smoother, as the reductions slowly become actualized over many days, instead of within the day.

Also diazepam is manufactured in liquid form commercially in the US, which can make going from 2.4mg to 0.5mg (a typical jumping off point) much easier to gradually reduce to.

Do you you have a supportive doctor?

Here's what I found in the Ashton manual about zolpidem...

In my experience, the only exception to the general rule of slow reduction is triazolam (Halcion). This benzodiazepine is eliminated so quickly (half-life 2 hours) that you are practically withdrawn each day, after a dose the night before. For this reason, triazolam can be stopped abruptly without substitution of a long-acting benzodiazepine. If withdrawal symptoms occur, you could take a short course of diazepam starting at about 10mg, decreasing the dosage as shown on Schedule 2.

 

The same approach applies to the non-benzodiazepines zolpidem and zaleplon which both have half-lives of 2 hours.

https://www.benzoinfo.com/wp-content/uploads/2019/04/Ashton-Manual-BIC.pdf (page 39)

My take away from this is that if your doctor supported this approach, you could to do a crossover to a slightly higher "equivalent" dose of diazepam and then taper this dosage. Otherwise, Dr. Ashton is saying you could just stop taking it abruptly.

Zolpidem is an interesting medicine; with a 2 hour half-life, you're fully withdrawn from each dose within the day. I doubt it's going to ever be a steady serum level unless you dosed hourly. The half-life means half the medicine has been eliminated from the body, typically, within two hours; that doesn't leave much time for it to have an effect.

Since you describe feeling inter-dose and tolerance withdrawal compared to your earlier usage, I suggest a crossover to a low dose of diazepam, stabilizing for a week or two after the crossover and tapering from there; stopping abruptly in your case may be too overwhelming.

I'll also reach out to buddies who have more experience with this medicine you're on...

Thank you so much for your help! I’m sorry - I don’t understand why you suggest crossing to a higher dose like 5-10mg. I thought the equivalent dose of valium was half that of zolpidem?

My worry when crossing is that I’m sensitive to the tiniest, tiniest cut in the zolpidem. So if I cut half of it, or even a quarter and replaced that with valium the first night, the valium wouldn’t yet have had time to build up in my system so I’d just feel the withdrawal effects of the zolpidem, wouldnt I?

If you wouldn’t mind helping me create a crossover plan that would be amazing! I’ve spoken to a doctor about prescribing valium. She’s conferring with a colleague and getting back to me. So hopefully she can help. I’m in the UK

Thanks so much again for your help

I must have edited my post while you were replying; sorry. I was trying to decide why Ashton was suggesting specifically a 10mg diazepam taper schedule. I was also considering you aren't stable at your current zolpidem dose. I decided against suggesting 5-10mg; I think something closer to where you are now in equivalency would be better, but a small increase in the diazepam dose might help you stabilize sooner before tapering and make it easier to make the transition with tablets. It was just an idea; I'm sorry to confuse you.

I hear you about feeling sensitive to zolpidem cuts. We won't really know how you respond to diazepam until you take some; there are two primary metabolites of diazepam, and both of them I believe are longer acting than your current medication. You may feel better from day 1 with diazepam, especially at your current dosage level, but I would prepare for some discomfort and adjustment, at least for the first few days. It may be surprisingly sedating, you may feel a little more depressed. But in any case, crossovers require some patience and tolerance to change.

I would be happy to work to create a crossover plan with you.

How often do you currently dose?

What times of day?

How much medicine at each dose?

Just a quick question - if updosing a little would make me stable and make the taper more tolerable, can I not just updose the zolpidem and taper from there, or would that not work? I was tapering fine on zolpidem last year - very slowly. But I held the dose stable for a year and that’s how the problems have started...

If you think diazepam is better, my current zolpidem schedule is 3.8mg at night and then 1mg when I wake early morning. I then go back to sleep.

My other worry is that if I give the diazepam a few days trial, by the time I realise it’s no good for me my body will already have become addicted to it? So then I’ll be stuck on it?...

Thank you so much again for your help. I’m writing short replies as it’s difficukt to look at my screen too long

No worries Ktkat999! You answered my questions. Two doses, 3.8mg at night and 1mg in the morning.

To answer your new questions...

First, I don't think it's worth bothering to updose the zolpidem presently if you plan to crossover. I know it seemed to be working for you before, but I hear it's not working now and your last updose didn't seem to resolve things enough. I'm suggesting if you do need an updose, to take in during the crossover and ideally by crossing over to a slightly larger dose of diazepam than is equivalent to your current zolpidem. It just makes more sense to me this way, but I'm only suggesting ideas. Zoplidem seems only to be causing you trouble at present...

Secondly, trialing diazepam for a few days to a week should not make you physically dependent on it from my understanding. You are physically dependent on benzo-like activity, so you can't stop both the diazepam and the zolpidem without withdrawal, but I think you should be able to easily switch back to zolpidem if you were having a bad reaction to the diazepam. At that point you'd likely be updosing the zoplidem and looking for a different crossover to make, so let's not get too far ahead of ourselves.

Here's my suggested crossover schedule:

Week 1: AM 1mg Z; PM 1mg diazepam (V) and 2mg Z

Week 2: AM 1mg Z; PM 2mg V

Week 3: AM 1mg V; PM 2mg V

After week 3 I suggest holding at this dosage until feeling stable and functional, and posting to the tapering boards for help tapering your new diazepam doses.

You'll notice I suggest crossing from 4.8mg/day Z to 3mg/day V; this is the small updose I was talking about, since you will end up on the rough equivalent of 6mg/day of Z. I also rounded up your PM Z dose on week 1 to 2mg from 1.9mg, as an option if this makes for easier dosing. The goal, in my mind, is your comfort and stability; I'm sorry we can't just fix everything at once but I tried to make this crossover plan as supportive as possible for your current condition.

What will hopefully happen is that by week two (only 7 days away from your start!), your nightly 2mg diazepam dose will be supporting you through the day time as well. Many people only need to dose diazepam once a day, due to it's long half life. Thus, if you complete this crossover, you could taper the AM dose first, and then continue to taper and dose only nightly.

I realize this is a scary adjustment. The crossover looks fast, but it may feel really slow as you take it day by day. I think that even week 1 of the crossover may help you a lot more than you yet realize.

Does this crossover plan suggestion sound like something you'd be interested in implementing?

Any adjustments you'd prefer?

Thank you so much! Just to let you know that I need to take a break from my screen - I also have symptoms from a head injury and long covid. So I will reply properly when I’ve rested my eyes - but I havent gone away!

Thank you again

Thank you so much! Just to let you know that I need to take a break from my screen - I also have symptoms from a head injury and long covid. So I will reply properly when I’ve rested my eyes - but I havent gone away!

 

Thank you again

No problem. I can be a bit verbose, trying to be thorough.

I'll be here whenever you have time to reply.

Rest well. 

Thank you so much again for doing that schedule for me. I haven’t been able to look at my screen at all the past few days and have been dying to get back to you. Sorry for the delay. Could I ask a few questions?...

Do people generally have more of a problem with diazepam liquid than tablets? Is it more likely I’d feel ill if I tried liquid?

Night time is more of a problem so is it possible I could put the updose there? But then that means doing halves, and if I’m using tablets that gets tricky...

Why am I only updosing in third week?

I don’t really understand the long half-life thing. Won’t the valium just accumulate over a matter of days so you’re on a higher and higher dose as the days go on?

If I had a bad reaction to the valium and went back to the zolpidem, would I then inadvertently be giving myself an overall higher dose as the valium would still be in my system? So once the valium cleared, I’d feel as if I’d cut the dose?

Thank you so much again. Sorry for the curt and list-like writing. It’s still so difficult to look at my screen so I’m having to do it in short bursts. I really appreciate your help and it’s so reassuring to communicate with someone who understands this stuff!

Katie

1. Do people generally have more of a problem with diazepam liquid than tablets? Is it more likely I’d feel ill if I tried liquid?

 

2. Night time is more of a problem so is it possible I could put the updose there? But then that means doing halves, and if I’m using tablets that gets tricky...

 

3. Why am I only updosing in third week?

 

4. I don’t really understand the long half-life thing. Won’t the valium just accumulate over a matter of days so you’re on a higher and higher dose as the days go on?

 

5. If I had a bad reaction to the valium and went back to the zolpidem, would I then inadvertently be giving myself an overall higher dose as the valium would still be in my system? So once the valium cleared, I’d feel as if I’d cut the dose?

Hi Katie,

It's very difficult for anyone, even with a medical background, to know what you will experience with medications. I will definitely try to answer your questions, but I just wanted you to know that it is your own trials that will ultimately determine "what does what" for you and your body. Unfortunately, this is just a reality of modern medicine.

1. Some buddies have reported difficulty transitioning to liquid diazepam. Liquid medicines are made in a variety of ways, with a variety of ingredients. I had a severe reaction to one oil-based proprietary vehicle for a liquid clonazepam, almost no medical potency from another oil-based simplified formula, and ultimately settled on an alcohol and water based solution specifically because it worked; these were three stressful trials, but made so much easier and safer because I only switched a small portion of my daily dosage to liquid, keeping the rest as familiar tablets. So yes, a transition to any liquid benzo seems to carry a risk of complications. I have no idea if you'd feel ill trialing liquid diazepam, but a liquid/tablet hybrid approach could minimize this risk. If possible, I suggest making the crossover with 2mg tablets and an aluminum pill cutter; only after the crossover would I suggest trialing any liquid diazepam.

2. I would suggest doing the crossover first before trying to do any fine-tuning like this. I think you may be surprised at how sedating diazepam is, and you are taking 2/3rds of your daily dose at night.

3. The equivalency charts are not perfect, there's no real way to know what is an updose and what isn't when changing medicines. I suggested a schedule that's primary goals are a transition to diazepam in more than two weeks, as you requested, and for ease of dosing; the updose just happens as a dosing convenience. In my mind, gradual changes in medication are ideal; you still won't know how you'll feel on diazepam until you try it. Patience is necessary in any gradual crossover.

4. In a way, yes, the diazepam doses will layer for a week or so and get a bit stronger every day. Past a certain point old doses will be eliminated as quickly as new doses are taken and your dosage will feel the same. This is expected, and it's part of the Ashton equivalency chart; diazepam as a single dose is a relatively low-potency medicine and 3mg would not be immediately comparable to 6mg zolpidem. But a gradual crossover allows the doses to layer so that they'll build up to the equivalency that I used to make the suggested schedule.

5. Yes, if you jumped immediately back to zolpidem, the previous diazepam doses would be in your system, and there would be a period of overlap. Fortunately diazepams long half-life gives it a very gradual elimination; this will likely minimize withdrawal effects. As I said before, if the crossover doesn't work, I suspect you'll want to try other options and likely increasing your overall benzo dose to recover stability. I suggest not worrying too much about future complications until you have them.

No problem being curt. I hope I answered your questions.

It sounds like you're struggling with a lot of fear right now. In the last year I've had VERY intense periods of fear running my brain and my whole life, and I found it very difficult to make decisions and take necessary risks. Unfortunately, life demands risks of us. It's awesome that you're reaching out on the forum, but our thread has in some ways mirrored your previous thread with Pamster.

It sounds like you can't stay on the zolpidem for much longer, and diazepam is the benzo with the best cost-vs-rewards that I know of for you to transition to. There seems to be a need in your case to step into the unknown, knowing you're frightened, and knowing that this process is beyond your control. I am reminded of "a leap of faith".

Don't hesitate to ask more questions. But I hope we can craft a small enough leap that you can see for yourself if diazepam is right for you; I'm fairly certain that only actual experiences of the medication will give you the perspective you're seeking.

You can do this! 

I think the biggest hurdle crossing over from Zolpidem to Diazepam isn't so much the conversion rate, which you can adjust until you find it confortable, but the fact that you are moving from a "pure hypnotic" to an anxiolitic with a mild sedating effect.

Like me, you've got used to take benzos if you wake up in the middle of the night. If you're going to experience strong insomnia during cross over and withdrawal perhaps you may give a try to sleep aids like low dose trazodone / mirtazapine or quetiapine.

Actually there is a good long half life benzo for sleeping problems, even longer than diazepam: flurazepam (dalmane). The main problem of flurazepam is that you can't break it and the only option available are 15mg and 30mg pills. That makes tapering pretty hard unless you can find a pharmacy which is able to prepare / compound what you need.

I think the biggest hurdle crossing over from Zolpidem to Diazepam isn't so much the conversion rate, which you can adjust until you find it confortable, but the fact that you are moving from a "pure hypnotic" to an anxiolitic with a mild sedating effect.

 

Like me, you've got used to take benzos if you wake up in the middle of the night. If you're going to experience strong insomnia during cross over and withdrawal perhaps you may give a try to sleep aids like low dose trazodone / mirtazapine or quetiapine.

 

Actually there is a good long half life benzo for sleeping problems, even longer than diazepam: flurazepam (dalmane). The main problem of flurazepam is that you can't break it and the only option available are 15mg and 30mg pills. That makes tapering pretty hard unless you can find a pharmacy which is able to prepare / compound what you need.

Thank you so much again for such kind and detailed answers. Yet again I can’t look at my screen at all with head injury symptoms so I’ll reply properly in a couple of days but just wanted to say thanks

Slownsteady, thank you again for being so kind and detailed in answering all my questions - I’m so grateful.

I’ve been so concerned with equivalency because in the past, if I change the zolpidem dose by even 1.5% I feel it dramatically that same night. So I was worried that any drop in the dosage during the crossover would do the same. But maybe I’m forgetting that Valium works differently as it stays around in your system for longer? So I guess you wouldn’t immediately feel the effects of tiny dose changes?

Yes you’re right - I am completely terrified at the moment. The withdrawal has put me in a permanent state of terror and fear all day. Plus because I’ve been housebound with long covid and head injury symptoms for over a year, I’m very aware the my body is so sensitive and the tiniest change might throw things... But I do undertstand you don’t have a crystal ball and the only way to really know is to try...

I’m continuing to weigh options in my mind at the moment as I’ve got to wait for my appointment with a new doctor who’s willing to prescribe Valium next week. In the meantime, I’m wondering about a last ditch attempt at upping the zolpidem to 5mg at night, 1mg in the morning. Then I’ll know I’ve tried everything and crossing is the only answer... I was wondering whether you’d mind letting me know what the crossover would look like in that case? Would it be more complicated with halves and three quarters of tablets?...

Thank you so much again

Katie

Yes, diazepam reductions will feel VERY different from zolpidem reductions; as I may have mentioned, diazepam reductions are often realized over weeks. It's an ideal tapering benzo for this reason.

If you do updose on zolpidem to 6mg/day, I would not suggest using any improvement as evidence you don't need a crossover. You've described yourself as in tolerance withdrawal and unable to safely taper the zolpidem. I'm fairly confident that all that an updose will do is possibly buy you a brief time period of increased comfort before it stops working again; that time period could be a month or a week or a day, we really don't know.

You're the best judge of your situation, but I suggest holding at your current dose. I believe reducing and recovering from these medications requires a broad support and skill base, filled with alternative options to meet the needs previously met by the medication. Skills and support such as: learning how to fall asleep, learning how to down-regulate a stress response, learning how to manage emotions, including fear, learning how to breathe deeply, etc. Are there other safe options you could explore now to help ease your discomfort?

I understand you're feeling over your head right now, so I'm not suggesting making things worse or staying in an unsafe situation. But my long-view is that none of these medications work forever, and thus all of them are delay tactics. I think the sooner you can find non-medication solutions to your distress, the more comfortable you will be moving forward in life.

Next week is coming soon! Hang in there Katie. 

Thanks so much. The reason I’m thinking of trying to delay is that I’m currently so ill in other ways and the withdrawal and lack of sleep is making it worse and worse. I’m alone in the house and unable to speak as my chest is so bad from covid, so I’m unable to talk on the phone for support. I have a thyroid problem which means I’m too exhausted to leave the house so can’t go for walks or meet anyone. And the head injury means that I often can’t look at my screen at all. This will get better with exercises, but it’s impossible to do them without sleep. So I’m in a bit of a catch 22 and not in a position to get any support... I feel I need a chance to get a little better before I can withdraw...

I’m suddenly questioning whether this is really tolerance withdrawal. Only because it came on so suddenly - months and months of great sleep, 10 hours a night, feeling fine during the day (a little interdose withdrawal but nothing terrible). Then suddenly from one night to the next I was having no sleep and horrendous withdrawal. The last time this happened it turned out I’d given myself a higher dose one night by mistake. I reverted to that dose and the problem resolved. It occurred to me that maybe because I’ve been splitting 10mg tablets in half and then scraping them that maybe there was more than 5mg in one of the halves and I’d accidentally had too much one night because of that?... Wouldn’t tolerance withdrawal come on more slowly?...

Thanks so much. The reason I’m thinking of trying to delay is that I’m currently so ill in other ways and the withdrawal and lack of sleep is making it worse and worse. I’m alone in the house and unable to speak as my chest is so bad from covid, so I’m unable to talk on the phone for support. I have a thyroid problem which means I’m too exhausted to leave the house so can’t go for walks or meet anyone. And the head injury means that I often can’t look at my screen at all. This will get better with exercises, but it’s impossible to do them without sleep. So I’m in a bit of a catch 22 and not in a position to get any support... I feel I need a chance to get a little better before I can withdraw...

 

I’m suddenly questioning whether this is really tolerance withdrawal. Only because it came on so suddenly - months and months of great sleep, 10 hours a night, feeling fine during the day (a little interdose withdrawal but nothing terrible). Then suddenly from one night to the next I was having no sleep and horrendous withdrawal. The last time this happened it turned out I’d given myself a higher dose one night by mistake. I reverted to that dose and the problem resolved. It occurred to me that maybe because I’ve been splitting 10mg tablets in half and then scraping them that maybe there was more than 5mg in one of the halves and I’d accidentally had too much one night because of that?... Wouldn’t tolerance withdrawal come on more slowly?...

Gosh, I am so sorry to hear how difficult your situation is. I feel silly suggesting deep breathing exercises and learning emotional regulation when you can't speak or move about easily enough to get medical help.

I am wondering why you don't have more care at this time, and I'm also wondering if inpatient would be a better place to do this crossover and to get the care that you need. Waiting for a doctors appointment seems an unreasonably slow timeline for the level of isolation and disability that you are describing; if I was in the condition you describe, I would be seriously considering going to the emergency room within the day.

To my knowledge it's never been established exactly how long anyone can stay on something like zoplidem and continue to receive therapeutic benefits. I believe the Ambien label says (or used to say) something about not using it for more than 10 days. I would not be surprised if you've reached the limit of it's effectiveness.

I don't think your symptoms are likely to be caused by some discrepancy in the distribution of medicine in a single tablet. I think this is extremely unlikely in pressed tablets, and even more unlikely if they have a score line.

I hope I'm not being rude but why aren't you receiving more care for your conditions?

Thanks, slownsteady for your kind reply. It is an insane situation - I can’t even watch tv because of the head injury symptoms, so I’m literally alone on the sofa all day with my eyes shut. Which is really unbearable with the anxiety - I’m struggling to get through each minute. I do have a carer who comes to make me food each evening, so that’s good. I think I’d be too nervous to stay anywhere as a patient, though - the covid cases are rising again in the UK. Also I don’t think unfortunately there are any in-patient facilities here who understand these drugs...

The doctor is willing to prescribe valium but I’m still waiting for the prescription. Still going back and forth in my mind, though. Can’t help feeling from everything I’ve read on these boards and what pamster said that I’d be transferring to a worse drug with more likelihood of protracted withdrawal. But in my current state I don’t think my body could take tapering the ambien directly... But am I adding months or years to my sentence by moving to Valium?...

Thanks for letting me know about the scored tablets - they’re pretty accurate, then, and not much chance of there being a discrepancy between the two halves?...

Thank you again for all your kind words and help - I so appreciate it

Katie

Ktkat999,

Thanks for explaining more of your situation to me. I'm so sorry to hear how difficult this has been for you. I am concerned because benzo tapering alone doesn't seem like it will address the variety of difficulties you described, and tapering itself can be mentally and physically taxing. Unfortunately I can only offer you tapering suggestions, but I hope that you can receive more care for your other health struggles; you deserve to feel better!

The doctor is willing to prescribe valium but I’m still waiting for the prescription. Still going back and forth in my mind, though. Can’t help feeling from everything I’ve read on these boards and what pamster said that I’d be transferring to a worse drug with more likelihood of protracted withdrawal. But in my current state I don’t think my body could take tapering the ambien directly... But am I adding months or years to my sentence by moving to Valium?...

I highly doubt that Pamster has said that diazepam is "a worse drug with more likelihood of protracted withdrawal". It should be just the opposite.

Framing benzo use as a prison is something I do regretfully often and it's not helpful for me. I believe that benzo use is delay tactic, and while it is over-prescribed, I think that we can still glean this benefit of delay as we find our way out of the maze, assuming we keep in mind that this is only ever a short-term, high-cost delay.

Diazepam is an excellent benzo if your body can tolerate it. It will lengthen your "sentence" in exchange for minimizing your withdrawal symptoms; that's just the nature of slow benzo tapering. For someone struggling like you are, I can only see this as a good thing.

Also your Ambien dosage is so low, you won't be on very much diazepam; some people crossover and start tapering from 30-40mg of diazepam because like myself they were on the equivalent of something like 2mg of clonazepam (Klonopin). I have several years of tapering ahead of me; instead you are far closer to the finish line. But it looks like that finish line isn't getting any closer with your current usage of Ambien.

You've got a suggested crossover schedule, you've got a diazepam script coming to you (I hope they gave you 2mg tablets), I think you'll want a good aluminum pill cutter, and as far as I can tell you don't have much to lose by trying the crossover!

It's your decision. So much of healing is self-empowerment and choice, so I celebrate that this forum is all about giving suggestions and allowing buddies to choose for themselves. I support you going back and forth in your head as long as you need to but I wanted to clarify some points you made which I didn't think were accurate.

Let us know what you decide! We're all cheering for you!